Endocrine Abstracts

Background: Hirsutism is a common and disturbing complaint among women attending endocrine clinics. It is caused by androgen excess and when severe, might progress to virilization. Virilizing adrenal tumors are a rare cause of hirsutism.

Case presentation: A 14 year old girl presented with primary amenorrhea, poor breast development (Tanner stage B1), hirsutism (Ferriman-gallwey score, FGS of 12/36) clitoromegaly (clitoral index >200 mm²). Hormonal investigations revealed grossly elevated total testosterone of 7.21 ng/ml and DHEAS > 15 mg/ml. MRI abdomen showed a large 10.7×7.5×7.4 cm adrenal mass, compressing adjacent organs. A diagnosis of virilising adrenal tumor was made and she underwent right adrenalectomy. Biopsy confirmed it to be adrenocortical carcinoma with mitotic rate 8–10 per 50hpf. She underwent adjuvant radiotherapy and is planned for mitotane therapy. Another young lady, 18 year old, presented with oligomenorrhea and hirsutism of one year duration. She was obese with FGS of 15/36, Tanner staging B5P5. She was diagnosed elsewhere to have PCOS and was referred to us for further management. Hormonal workup revealed elevated total testosterone (1.45 ng/ml) and markedly elevated DHEAS (>15 mg/ml). Further workup revealed a normal 17 hydroxy progesterone and a suppressed ONDST. MRI abdomen showed a 3.5×2.6×4 cm left adrenal mass confirming the diagnosis of virilizing adrenal tumor. She underwent left adrenalectomy and biopsy confirmed it to be adrenocortical carcinoma. Post surgery she resumed regular menstrual cycles.

Conclusions: Rapid onset and progression of hirsutism along with very high DHEAS levels should prompt workup for virilizing adrenal tumors. Virilization could be a presenting symptom of androgen secreting adrenocortical carcinoma. Diagnosis of ACC in early stages and timely intervention, might improve survival in a tumor with otherwise very grave prognosis